Two entities loom large in our second issue of 2014: (1) populations whose primary language is not English (especially Spanish-speaking populations in North and Central America and the Caribbean, but also speakers of Asian languages and residents of Senegal and Niger); and (2) health care settings—ranging from hospitals to community health centers to private primary care practices to free clinics to shelters to the street itself.
Theme 1: Linguistically-Identified Populations and Health
Within counties and across countries, languages represent culture in the most deep-seated way possible. Languages serve as markers of cultural identity and, viewed more closely, yield rich information about cultures. Spanish, Chinese, Vietnamese, Korean, and languages spoken in the predominantly Muslim West African nations of Senegal (Wolof, Fula, Serer, French, and others) and Niger (Hausa, Zarma, Fulani, Tuareg, French, and others) all come into the stories told in the articles in this issue, especially Spanish. The authors of the ACU Column, which concerns barriers to contraceptive care faced by low-income and otherwise marginalized women, remind readers of Sankofa—the West African (Akan) symbol representing the importance of examining the lessons of our past in order to reach the full potential of our future. I hope the articles gathered together here contribute to such examinations.
Fundamental to good health care is good communication among patients, staff, and caregivers. Baig and colleagues report from Chicago on a study of the Spanish language ability and cultural awareness of community health center staff and providers working with large numbers of Latino patients with diabetes, and identify specific areas for improvement. Berkowitz and colleagues also assessed the status of Latino patients in the Diabetes Study of Northern California, reporting that low income and low educational attainment are important risk factors for hypoglycemia. In a Report from the Field, Sanchez and colleagues from Texas describe the outcome of an Office of Minority Health meeting on eliminating health disparities through culturally and linguistically integrated care, concluding with the identification of key strategies to achieving this end. Connections between the quality of patient-provider communication among Puerto Ricans, socio-demographic variables, and health status occupy William Calo and colleagues in their Brief Communication. Maranda and colleagues at a community health center in New York City conducted an intervention designed to enhance patient activation and report on signs of its effectiveness among Spanish-speaking patients.
It has previously been found that, in the United States, metropolitan areas with laws prohibiting over-the-counter (OTC) sales of syringes have a higher mean HIV prevalence than other metropolitan areas. Pollini and colleagues examine OTC syringe sales in Tijuana, Mexico, where such sales are legal, by means of a survey of over 200 pharmacies. They report that, despite the legality of the practice, a large majority (74%) of respondents reported that their pharmacy required a prescription for a syringe purchase.
Religion and church teachings positively influence the cancer screening practices of Catholic Latinos in Massachusetts, according to Allen and colleagues from Dana-Farber, Harvard, and Boston College. Participants in the eight focus groups they conducted emphasized that their parish leaders strongly encouraged cancer screening, expressed willingness to participate in health education programs in their parishes, and provided practical recommendations for implementing such health programs.
Forty women living in Guatemala participated in a qualitative study of cervical cancer and HPV knowledge, attitudes, beliefs and behaviors. Petrocy and Katz, who conducted the study, report that while knowledge was low, openness to receiving the vaccine and in getting it for daughters is high. Nguyen and Belgrave report on the interaction of ethnic identification and the effectiveness of a breast and cervical cancer screening intervention among Vietnamese women living in the United States, reporting that higher ethnic identification was associated with less effectiveness. Lee, Choi, and Jung, using the California Health Interview Survey, studied access to health care among three Asian sub-groups (Chinese, Vietnamese, and Korean). While they find that poverty and insurance status commonly impede access to care, there are differences worth noting among the subgroups. First, Koreans had by far the worst access to a regular source of care (45.2%), relative to both Vietnamese (59.8%) and Chinese (78%). Furthermore, poverty status was the only significant predictor of access for Koreans, insurance status the only significant predictor for Vietnamese, and both were significant predictors of access for Chinese.
Pregnancy can be a time of great stress as well as joy. Being a minority group member, especially if one’s group is marginalized, also strains one’s sense of well-being. Finally, being immersed in a new culture, too, provokes anxiety in many people. Fleuriat and Sunil, at the University of Texas at San Antonio, studied pregnant Mexican American and pregnant Mexican immigrant women with respect to subjective social status, perceived social stress, depressive symptoms, and pregnancy-related anxiety. The two groups differed. The Mexican American women had higher levels of depression and perceived social stress. The Mexican immigrant women, in contrast, had higher levels of pregnancy-related anxiety. These findings should be helpful in developing culturally responsive prenatal care and psychosocial support.
Family planning is another phenomenon where cultural factors weigh heavily. Hossain, Ahmed, and Rogers asked whether a woman’s level of education correlated with the level of spousal agreement about family planning in the predominantly Muslim countries of Senegal and Niger. They found a strong effect: the level of spousal agreement was approximately three times as high in couples where the wife had more than primary education than in couples where she had less. Improvement in women’s education, the authors conclude, could contribute to greater success in women’s family planning.
Theme 2: Health Care Settings
As health policy and practice evolves in response to advances in knowledge and understanding, the force fields of economics and law, and perpetual diversification of social groups, so too the places where practitioners and patients meet evolve. The rest of this note is organized according to site of care.
Hospitals. Two Reports from the Field and five Original Papers concern care received in hospitals or after hospitalization. The Report by Roose and colleagues from Albert Einstein College of Medicine in the Bronx is about an innovative peer educator program to reduce barriers to hepatitis C treatment among opioid drug users. The second Report concerns medical education: Malika Sharma describes a new curriculum on marginalization and health at an inner-city academic hospital in Toronto.
Sabrina Assoumou and colleagues at the Boston University School of Medicine also seek to improve hepatitis C virus treatment, and rigorously studied the slowly increasing adequacy of treatment between 2005 and 2011 at an urban safety-net hospital. Post-hospital care presents another challenge, especially for older patients of low socioeconomic status. A Philadelphia-based team led by Shreya Kangovi found that socioeconomic stressors (that make accessing post-discharge care and accommodations difficult) and a felt lack of empathy among people to whom they looked for help made the transition more difficult for the participants in their study.
Two papers concern emergency room (ER) use. Mahabee-Gittens and her Cincinnati-based team incorporated a brief, parental tobacco prevention intervention to parents of pediatric patients in an ER, many of whom had low incomes and/or were African Americans and nearly 30% of whom smoked. The parents reported finding the intervention helpful and easy to understand, and that it did not interfere wither their children’s care. Using Medical Expenditure Panel Survey (MEPS) data, Karoline Mortensen analyzed the relationship between Medicaid enrollees’ access to primary care providers and their use of ERs, finding that increasingly poor access to primary care correlated with increased ER use. The author points out that this underscores again the importance of shoring up the availability of primary care providers taking new Medicaid patients as the ACA goes into broad effect. Finally a Texas team led by Bryan Schneider developed and applied a system for prioritizing the need for inpatient. hospital services among prisoners. Nearly all the inpatient admissions they studied (94%) ranked as medically mandatory or medically necessary—in other words, the services must be given and therefore funding for them must be budgeted by states. The mechanism the team developed for prioritizing cases may be helpful to state policymakers nationwide.
Community health centers. A Commentary by Isringhausen and colleagues at Virginia Commonwealth University recommends establishing formal partnerships between community health centers and nearby dental schools in order to increase the amount of oral health care available to low-income patients. They geocoded dental school and federally qualified health center (FQHC) sites in the continental U.S. and found that on average dental schools are within 10 miles of 34 FQHC sites. Women, Infants and Children (WIC) program sites are another sort of health center. Donna Lockner and her team report on a random-control design study of an intervention to promote skills training, tools, and a wellness program for staff at the 48 WIC clinics in New Mexico, with the goal of improving staff members’ own conceptions of their physical selves and their functioning. The staff who participated in the Get Healthy Together program reported improved confidence and ability to counsel the parents of overweight children. Unusually, this intervention appeared to have beneficial effects for three affected populations: WIC staff, WIC parents, and WIC children.
The federal service program, AmeriCorps, sometimes provides staff to CHCs to assist with case management. Stipelman and her Utah-based team compared the rates of Medicaid/CHIP insurance at an urban FQHC that had AmeriCorps staff providing case management with those at a similar FQHC that did not have AmeriCorps staffing. (Both clinics predominantly serve Latino populations.) Nearly three-fourths (74%) of the children at the AmeriCorps-staffed clinic were enrolled in health insurance whereas only 26% of those at the non-AmeriCorps-staffed clinic were. Furthermore, the children at the former clinic were more likely to receive preventive care, despite sliding-scale billing at both clinics. Consumer governance of some sort (“maximum feasible participation”) has been a feature of CHCs since they were first established in 1965 as part of President Lyndon Johnson’s War on Poverty. Wright and Martin explored by means of extended interviews with 30 trustees in 14 states the role of consumer trustees in decision-making at CHCs. In general, they reported that the CHC boards on which they sit do influence the decisions about how margin and mission are balanced, but that executive directors and clinic staff exert more influence.
Free clinics and student-run clinics. Four papers in this issue concern themselves with free clinics or student-run free clinics. Petrany and Christiansen used a pre-test/post-test design to evaluate knowledge of the ACA among 100 uninsured patients at a free clinic in West Virginia. Knowledge was low on the pre-test, relative to national averages, but improved markedly after the video. Another Utah-based paper, by Kamimura and colleagues, finds high prevalence of intimate partner violence (IPV) among people visiting a free clinic, and also found that IPV in this population is associated with poor health outcomes (especially mental health). In another paper bearing on medical education, Smith and others from the University of California at San Diego School of Medicine surveyed nearly 1,000 people who had taken the 1st or 2nd year service-learning course in which they worked at the student-run free clinic project there between the years of 2001-2010. The response rate was very high, as were the reported effects on reported knowledge, skills, attitudes and self-efficacy with the underserved, interest in primary care, and interest in working with the underserved.
Finally, Peluso and a team from Yale’s School of Medicine report of the successful management of latent tuberculosis infection in a low-income, largely non-U.S.-born population at the HAVEN Free Clinic. They achieved results comparable to the most successful programs reported on in the literature. This is important as the threat of latent tuberculosis infection is severe, and the course of treatment long (nine months) and not motivated by symptoms. It is also important that the authors report on the death of a program participant: the patient developed INH toxicity and was seen at Yale-New Haven Hospital; while there, she underwent a diagnostic procedure on her liver, developed complications, and died. Her death was publicized when it happened, and became the subject of a self-study conference at Yale; it was not a result of her care at the HAVEN Free Clinic.
Other settings. A team led by Sarah Woods investigated the incidence of family discord among patients (N=125) at an urban primary care practice and associated psychiatric co morbidities, reporting it to be very high. In another paper bringing together researchers from Yale and the University of Utah, Echo Warner and colleagues studied the health care concerns of rural people who had survived childhood cancer. The survivors frequently expressed concerns about what care was available to them locally, but also expressed willingness to travel long distances to get better care. Studying data from the Behavioral Risk Factor Surveillance System (BRFSS), Okoro, Dhingra, and Li found that adults with disabilities who suffered psychological distress also had higher prevalence of chronic conditions, barriers to health care, and non-receipt of preventive cancer screenings.
Two papers set in the New York-New Jersey area concern urban children with asthma. Rastogi’s team from Albert Einstein College of Medicine found that the quality of life among obese asthmatic children did not differ from that of pre-adolescent inner-city children (some with asthma, some who were obese but not asthmatic, and some who were neither obese nor asthmatic). The authors conclude that asthma severity may not serve as a surrogate marker of quality of life. Cutuli and colleagues examined rates of asthma among children staying in family emergency shelters and how it related to adaptive functioning and health care use. The rate of asthma among 4-6 year olds was 21%, approximately double state and national averages. The children with asthma had worse peer relationships and used more health services than other children; they did not differ on academic, cognitive, and school behavioral measures.
Sara Kennedy led a team that qualitatively studied pregnancy intention and the use of contraception among homeless women with children. The 22 women interviewed expressed a strong preference not to become pregnant while homeless, but also cited competing demands as depressing their care of their own health, structural barriers (shelter and health system) to contraception, and decreased power in sexual relationships when homeless. Jack Tsai’s team based at a Veterans Affairs (VA) research center and Yale University studied the characteristics of homeless individuals seen at the VA after being engaged through street outreach. In 2011-2012, nearly 71,000 literally homeless veterans engaged in VA homeless services and 12% of them were engaged through street outreach. This sub-group was characterized by more chronic homelessness and was more likely than the rest to be referred and admitted to the VA’s supported housing program. The authors conclude by underscoring the importance of street outreach for serving those people who are homeless most direly in need of care.
Finishing this summary, I am again brought up sharply to recognize that the medical, dental, and mental health care needs of often disempowered people compel our attention. The work of the researchers, clinicians, and community leaders that we see here should help light the way to a place where those needs are met.
Virginia M. Brennan, PhD, MA
Assoc. Professor, Meharry Medical College